Breast cancer

Is it time to curb overuse of neoadjuvant chemotherapy?

Neoadjuvant chemotherapy has come into widespread use in breast cancer based on a flawed rationale and it is now time to limit its use, UK oncologists say.

In an article in The BMJ, a group of UK-based oncologists say the dramatic shrinkage of primary tumours seen with neoadjuvant chemotherapy does not translate into survival benefits and the treatment may increase rates of recurrence.

Professor Jayant Vaidya (pictured), consultant breast cancer surgeon at University College London, and colleagues, say that three meta analyses have shown that neoadjuvant chemotherapy does not confer any survival benefit compared with adjuvant chemotherapy.

While neoadjuvant chemotherapy may shrink tumours, trials show it only allows 17% patients to avoid mastectomy and this comes with a 6% absolute increase in risk of recurrence, they note.

It has become apparent that the pathological responses to neoadjuvant chemotherapy in primary tumours are not seen in metastatic sites. In addition, neoadjuvant chemotherapy makes tumours more diffuse and with less palpable margins, which makes surgical removal less precise, they say.

They warn that the increasing use of neoadjuvant chemotherapy in smaller and better prognosis tumours means women have to live with aggressive chemoresistant cells in the breast throughout six months of treatment.

“The time may have come for a “medical reversal,” as new trial data contradict current clinical practice of the widespread use of neoadjuvant chemotherapy even for patients with HER2 positive or triple negative disease,” they write.

“We must acknowledge that neoadjuvant chemotherapy may not be beneficial to patients [and] should consider reducing the widespread use of neoadjuvant chemotherapy.”

They recommend that neoadjuvant chemotherapy should be considered only in patients who are on the borderline of being suitable for breast conservation, in whom a smaller resection might be feasible if there is a response, and if the tumour type is likely to respond.

If neoadjuvant chemotherapy is used, the lack of survival benefit and higher risk of local recurrence should be explained to the patient, they add.

Their survey of multidisciplinary teams including Australia found that 7-27% of new breast cancers are treated with neoadjuvant chemotherapy.

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